1. Medanta, The Medicity, Gurgaon 2. Artemis Hospital • Gurgaon • Dwarka, Delhi 3. Columbia Asia ...

16 Pages·2014·0.09 MB·English

PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ANY ONE OF THE FOLLOWING APPROVED HOSPITALS
FOR EXECUTIVE CHECK-UP (For employees & their spouses who are 45 years & above only)

I am willing to avail of the Executive Health Check-up for self and spouse as per details given below:

Name……………………………………. Designation ……………………… Emp. No. .………….. Division ………......……………….
DOB/Age …………………..............…………… Status : Reg./ Dep. Opted RITES Medical Facility (Yes / No)
Intercom No…………… Mobile …………………Spouse Name (Mr./Mrs.)………..................................... DOB/ Age .........................
1. Medanta, The Medicity, 2. Artemis Hospital 3. Columbia Asia Hospital
Gurgaon  Gurgaon  Palam Vihar, Gurgaon
 Dwarka, Delhi  Ghaziabad

4. Primus Super Specialty 5. Balaji Action Medical 6. Kailash Hospital
Hospital, Chankya Puri, New Institute, Paschim Vihar,  Sector – 27
Delhi New Delhi  Sector 11, Gr. Noida

7. Deepak Memorial Hospital 8. PSRI Hospital, Sheikh 9. National Heart Institute, East of
Vikas Marg, Delhi Sarai, New Delhi Kailash, New Delhi

10. Rockland Hospitals 11 Indraprastha Apollo 12. Metro Hospital & Heart Institute
 Qutab Area, New Delhi Hospital, Sarita Vihar,  Sector – 11, Noida
 Manesar, Gurgaon New Delhi  Preet Vihar, Delhi
 Dwarka, New Delhi  Palam Vihar, Gurgaon

13. Escorts Heart Institute, 14. Batra Hospital, 15. Dr. B. L. Kapur Mem. Hospital,
Okhla, New Delhi Tuglakabad, New Delhi Pusa Road, New Delhi

16. Moolchand Hospital, Lajpat 17. Alchemist Hospital 18. Paras Hospital, Sushant Lok,
Nagar, New Delhi Gurgaon Gurgaon

19. Fortis Hospital
 Sector – 62, Noida
 Vasant Kunj, New Delhi
 Neelam Chowk, Faridabad
 Karol Bagh, New Delhi
 Shalimar Bagh, Delhi

( ) Please tick against the hospital & location.

Signature..................................

Date: ........................................

Signature of the Controlling Officer with Designation
PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ONE OF THE APPROVED HEALTH CHECK-UP PACKAGES IN ANY
OF THE FOLLOWING HOSPITALS
(For employees & their spouses who are 45 years & above)

I.………………………………………..…......…. am willing to avail of the Health Check-up package for self and / or for my spouse

(Mr./Smt…….............………………………..............………..(Date of Birth………………….........…….) as per my choice given below:-

ESCORTS HOSPITAL APOLLO HOSPITAL NATIONAL HEART INSTITUTE
Okhla Sarita Vihar East of Kailash
Executive Check-up Executive Check-up Executive Check-up
For males Rs.3000/- For males Rs.3000/- For males Rs.2800/-
For females Rs.3250/- For females Rs.3000/- For females Rs. 3200/-
FORTIS HOSPITAL
BATRA HOSPITAL TIRATH RAM HOSPITAL
Vasant Kunj / Noida / Faridabad
Mehrauli Badarpur Road Rajpur Road
Karol Bagh / Shalimar Bagh.
Executive Check-up Executive Check-up Executive Check-up
For males
Rs.3000/-
For males/females Rs.2100/- For males/females Rs.2175/-
For females Rs.3250/-
MEDANTA THE MEDICITY COLUMBIA ASIA ALCHEMIST HOSPITAL
Sector-38, Gurgaon. Palam Vihar, Gurgaon. Sector -53, Gurgaon
Executive Checkup Executive Checkup
Comprehensive Check up

For males/females Rs.3500/- For males/females Rs.3000/- For males &females Rs.3000/-
DR.B.L. KAPUR HOSPITAL Moolchand Hospital
Pusa Road, New Delhi Lajpat Nagar, New Delhi
Executive Checkup (For
Rs. 3000/- Executive Checkup (For males/females)
males/females) Rs. 3000/-
Kailash Hospital & Heart Institute St. Stephen’s Hospital,
H-33, Sector-27, Noida Tis Hazari, Delhi
Executive Checkup (for
Rs. 2450/- Executive Checkup (for Males / Females) Rs. 3200/-
Males/Females)
Asian Institute of Medical Sciences Paras Hospitals
Sector-21 A,Faridabad-121001 C-1, Sushant Lok, Sector-43, Gurgaon
Executive Checkup (for
Rs.4000/- Executive Checkup (for Males/Females) Rs. 3150/-
Males/Females)
Park Hospital
Outer Ring Road,New Delhi / Malviya Nagar,New Delhi / South City-II,Gurgaon / Sector-10,Faridabad
Executive Checkup (for Males/Females) Rs. 3000/-

( ) Please tick against the package of the hospital & location.

Name……………………………………. Designation ……………………………… Emp. No. ………………………….. Division
……………………….

DOB ……………………………………… Status : Regular/Deputation, Whether opted RITES Medical Facility (Yes/No)

Intercom No………………………….. Mobile / Landline No…………………………………

Signature......................................... Dated:…………………………….

Signature of the Controlling Officer with Designation
List of investigation & Clinical tests at the hospitals/Clinics for Health Check-up programme

Escorts Hospital/Okhla
Fortis Hospital Apollo Hospital National Heart Institute
Vasant Kunj/Noida/Faridabad/ Sarita Vihar East of Kailash
Karol Bagh/Shalimar Bagh.
Comprehensive Check-up Health Cheq Executive Health Checkup
Doctors Consultations & full medical exam. Haemogram Doctors Consultation & Full
Blood Tests Haemoglobin medical examination
Complete haemogram (Hb, TLC,DLC, MCHC, MCV, MCH Blood Tests
ESR, Haematocrit, Peripheral Smear) Differential count - Complete Haemogram (Hb,
Blood Group (ABO, RH), Blood Sugar Platelet count TLC, DLC, ESR, Haematocrit &
(Fasting & Post Prandial), Blood Urea, PCV, Total WBC Peripheral Smear)
Serum Uric acid, Serum Creatinine, Peripheral smear Blood Group (ABO, Rh)
Serum Cholesterol, Lipid Profile Blood Sugar (Fasting & PP)
Biochemical Parameters Blood Urea
Urine Examination, X-Ray Chest PA, ECG Blood Sugar (Fasting &PP) Serum Uric acid
Exercise Stress Test (TMT), Stress Uric Acid, Urea Creatinine Serum Creatinine
Screening by Psychologist, Eye Lipid Profile, Total Cholesterol Lipid Profile
Examination, Post Checkup consultation, HDL Cholesterol Urine Examination
Gynecologist Consultation & Pap Smear Triglycerides screening, Total X-Ray Chest PA
Test, (For females) Cholesterol/HDL Ratio ECG
Executive Health Checkup Exercise Stress Test (TMT)
Tests in Comprehensive checkup Plus Liver Function Tests Liver Function Test
Stool RE Total Protein, Globulin, SGPT, GGTP, Pulmonary Frnction Test / Thyroid
Pulmonary Function Test (Routine) Albumin, A/G Ratio, - profile
Liver Function Test (includes SGOT) Alkaline Phosphatase Ultra Sound Whole Abdomen
Ultra Sound whole abdomen Basic Eye Examination
General Tests Basic Dental Check-up
VDRL, Complete Urine analysis Gynecologist Consultation &
ECG (Resting) PAP Smear Test
Ultrasound abdomen screening Post Check up Consultation.
Blood Grouping & RH-typing
ALCHEMIST HOSPITAL Faeces examination Moolchand Hospital
Sector -53, Gurgaon X-Ray Chest Lajpat Nagar, New Delhi
Clinical examination, Medical Summary
Blood Grouping & Rh type, DLC,
& advice by Sr. Consul-tant, Internal
Comprehensive Checkup Medicine, Genital/Rectal examination by ESR, Haemoglobin
Haemogram: Sr. General Surgeon/Gynecologist. MCV/MCH/MCHC, Packed Cell
Haemoglobin, MCHC, MCV, MCH, Different Volume, Platelet count, Peripheral
count, Platelet count, PCV, Total WBC, count, RBC count, RDW, TLC
Peripheral smear Biochemistry
Blood Sugar F & PP, Blood Urea,
Biochemical Parameters: S.Creatinine, Uric Acid,
Blood Sugar (F&PP), Uric Acid, Urea Liver Function Test
creatininr, NA, K, Ca, PO-4, Albumin/Globulin Ratio, Alkaline
Phosphatase,
Executive Health Cheq
Lipid Profile, Total cholesterol : Bilirubin Total/Direct/Indirect, S.

HDL Cholesterol, Triglycerides screening, Calcium & S. Phosphorus
Full Package of Health Chaq mentioned
Total Cholesterol, HDL Ratio S. Protein/Albumin/Globulin,
above Plus Pulmanary Function Test
SGOT/SGPT/SGGTP, Lipid Profile,
(PFT) Tread Mill (TMT)
Fiver Function Test : PAP Smear (For f.males)
Total Protein, Globulin, SGPT, GGTP, Stool-Routine, Urine Analysis
Albumin, A/G Ratio, Alkaline Phosphates ECG, Ultra Sound (L & U Abdomen),
X-Ray PA.
General Tests : Consultation
Complete Urine analysis, ECG (Resting), Medicine, Gynae (for females)
Ultra Sound abdomen screening, X-Ray Opthalmology & Dental
Chest, TMT/Echo, PFT, Consult with Executive Health Checkup
internal Medicine, Gynecologist for female, Comprehensive Checkup Plus TMT
Consult with Surgeon. & PFT (basic Spirometry)
PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ONE OF THE APPROVED HEALTH CHECK-UP PACKAGES IN ANY
OF THE FOLLOWING HOSPITALS

I.………………………………………..…......…. am willing to avail of the Health Check-up package
for self and / or for my spouse (Mr./Smt…….............………………………..............………..(Date of Birth………………….........…….) as
per my choice given below:-
ESCORTS HOSPITAL, Okhla APOLLO HOSPITAL NATIONAL HEART INSTITUTE
Sarita Vihar East of Kailash
Comprehensive Checkup Health Cheq. Executive Health Check
For males Rs.1850/- For males/females
Rs.2100/-
For females Rs.2100/- For males Rs.2800/-
Executive Check-up Executive Cheq
For males Rs.3000/- For males/females Rs.3000/- For females Rs. 3200/-
For females Rs.3250/-
FORTIS HOSPITAL
BATRA HOSPITAL TIRATH RAM HOSPITAL
Vasant Kunj / Noida / Faridabad
Mehrauli Badarpur Road Rajpur Road
Karol Bagh / Shalimar Bagh.
Comprehensive Checkup Executive Check-up Comprehensive Checkup
For males/females For males/females For males Rs. 1850/-
Rs.1600/- Rs.1500/-
For females Rs.2100/-
Executive Health Check Heart Check Executive Check-up
For males/females For males/females For males Rs.3000/-
Rs.2100/- Rs.2175/-
For females Rs.3250/-
MEDANTA THE MEDICITY COLUMBIA ASIA ALCHEMIST HOSPITAL
Sector-38, Gurgaon. Palam Vihar, Gurgaon. Sector -53, Gurgaon
Comprehensive Checkup Comprehensive Checkup Comprehensive Checkup
For males/females For males/females For
Rs.2650/- Rs.2100/- males Rs.3000/-
Executive Checkup Executive Checkup
For males/females For males/females For
Rs.3000/-
Rs.3500/- Rs.3000/- females
DR.B.L. KAPUR HOSPITAL
Moolchand Hospital
Pusa Road, New Delhi
Lajpat Nagar, New Delhi
Comprehensive Checkup Rs. 2300/- Comprehensive Checkup Rs.2300/- & Rs.2600/-
Executive Checkup Rs. 3000/- Executive Checkup Rs. 3000/-

( ) Please tick against the package of the hospital & location.

Name……………………………………. Designation …………………. Emp. No. …………….

Division………………..........……..…DOB……...........……………..Status : Regular/Deputation
Whether opted RITES Medical Facility (Yes / No)

Intercom No…………… Mobile /Landline No…………………………………

Signature......................................... Dated:…………………….

Signature of the Controlling Officer with Designation
Batra Hospital Tirath Ram Shah Madanta The Medicity
Mehrauli Badarpur Road. Rajpur Road Sector-38, Gurgaon.
General Health Check-up General Health Check Comprehensive health Checkup

Clinical Examination by Sr. Haemogram Complete Haemogram, ESR,
Consultant, internal medicine. - Haemoglobin Haematocrit, Blood Group (ABO, RH)
Eye examination by Sr. Consultant - Different Count Blood Group (F & PP), Blood Urea,
Ophthalmology - Platelet Count Serum Uric Acid, Serum Creatinine,
Haemogram, Haemoglobin - PCV Serum Cholestrol, Lipid Profile,
Different Count - Total WBC Stool routine examination, Urine
- Platelet Count - Peripheral Smear examination, X-Ray Chest, ECG, Ultra
- WBC - History & full General Examination Sound (whole abdomen), Stress
- Peripheral Smear screening by psychologist, Eye
- MCHC Gynae check-up by Gynecologist (Women) examination, Post examination
- MCV Sr. Surgeon (Men) consultation, Gynecologist
- PCV - MCHC conbsultation & Pap smear test,
- MCH - MCV
- MCH Executive Health Checkup
Diabetic & Renal Parameters Diabetic & Renal Parameters
- Blood Sugar (F&PP) - Blood Sugar (F&PP) (Comprehensive Checkup) plus
- Uric Acid - Uric Acid PFT (Routine), LFT (includes SGOT),
- Urea - Urea Exercise Stress Test (TMT)
- Creatinine - Micro Albuminuia
- Urinary Micro Albuminuia - Creatinine
Columbia Asia
Lipid Prifile Lipid Prifile Block-F, Palam Vihar, Gurgaon
Total Cholelsterol (Including SERUM Cholesterol, HDL,

HDL, LDL LDL, Cholesterol, Triglycerides)
Comprehensive Checkup
- Triglycerides, Glycoslated Hb
Haemogram
Liver Function Tests
Haemoglobin, MCHC, MCV, MCH,
Liver Function Tests - Total Proteins
Different Count, Platelet Count, PCV,
- Total Proteins - Albmin
Total WBC, Peripheral Smear
- Albmin - Globulin
Biological Parameters
- Globulin - A/G Ratio
Blood Sugar (F & PP), Uric Acid,
- A/G Ratio - SGOT, SGPT, SGGT
Uric Creatinime
- SGOT, - SGPT - Alkaline Phosphatase
Lipid Profile
- Alkaline Phosphatase
Total Cholesterol, HDL Cholesterol,
- SGGT General Tests
Triglycerides Screening, HDL Ratio
Thyroid Function Tests - Complete Urine & Stool routine
Liver Function Test
- F-T3, F-T4, & F-TSH analysis
Total Protein, Globulin, SGPT,
- ECG (Resting )
GGTP, Albumin, A/G Ratio,
General Tests - Ultrasound of whole abdomen
Alkaline Phosphates
- Urine & Stool routine & ME - Blood Grouping & RH Typing
General Tests
- (Resting ) ECG - X-Ray Chest (PA view)
VDRL, Complete Urine analysis,
- Blood Grouping & RH Typing
ECG (Rating), Ultra Sound abdomen
- X-Ray Chest (PA view) Executive Health Check
screening, Blood Grouping & RH typing,
- PEFR (General Health check) plus
Faeces examination, X-Ray Chest,
- Gynecologist consultation - HBSAG
Consult with internal medicine,
- Final Assessment & report by Sr. - TMT (Treadmill exercise Test)
Consult with Gynecologist for female,
Consultant, Internal Medicine
Consult with Surgeon.

Executive Health Check Heart Check Executive Health Checkup
Tests in Comprehensive checkup Plus
All tests of Batra General Health All tests of Executive Health Check TMT
Check PLUS Ultra Sound L&U PLUS PFT
abdomen, Cardiac Function Test Echocardiography & Cardiac Check up
TMT & ECG by Cardiologist
RITES LIMITED
Welfare Section

Case No………..…….
Date:………………....

PROFORMA FOR RELASING MEDICAL ADVANCE FOR INDOOR TREATMENT

NAME:……………………………………………………………
Design. /Division …………………………………………….
Emp. No:…………………………………………………………
Place of Posting………………………………………………….
Patient Name………………………………………....Relationship…………………………
Illness……………………………………………..................................................……..
Name & location of Hospital…………………………………………………………………
----------------------------------------------------------------------------------------------
Estimate with Breakup given by hospital………….……………………………………..
Payment of Advance 80% of Rs…………………………….
.....................................................................................................................

.....................................................................................................................
.....................................................................................................................
Sanction may kindly be accorded for medical advance of Rs…………………...……
Payment may be released in favour of …………………………………...………………. ......................................................by a
crossed cheque.

Excess amount if any paid beyond the admissibility would be adjusted as per existing rules.

Dependency checked from official records
SO (Welfare)

JGM (Welfare & Protocol)

GGM (Admn)

GM (FE)
RITES LIMITED
Welfare Section

Case No………..…….
Date:………………....

PROFORMA FOR RELASING MEDICAL ADVANCE FOR INDOOR TREATMENT

NAME:……………………………………………………………
Design. /Division …………………………………………….
Emp. No:…………………………………………………………
Place of Posting………………………………………………….
Patient Name………………………………………....Relationship…………………………
Illness……………………………………………..................................................……..
Name & location of Hospital…………………………………………………………………
----------------------------------------------------------------------------------------------
Estimate with Breakup given by hospital………….……………………………………..
Payment of Advance 80% of Rs…………………………….
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Sanction may kindly be accorded for medical advance of Rs…………………...……
Payment may be released in favour of …………………………………...………………. ......................................................by a
crossed cheque.

Excess amount if any paid beyond the admissibility would be adjusted as per existing rules.

Dependency checked from official records
AM(P)/ (Welfare)

JGM (Welfare & Protocol)

GGM (Admn)

GM (FE)
RITES LIMITED
Welfare Section

Case No………..…….
Date:………………....

PROFORMA FOR RELASING MEDICAL ADVANCE FOR INDOOR TREATMENT

NAME:……………………………………………………………
Design. /Division …………………………………………….
Emp. No:…………………………………………………………
Place of Posting………………………………………………….
Patient Name………………………………………....Relationship…………………………
Illness……………………………………………..................................................……..
Name & location of Hospital…………………………………………………………………
----------------------------------------------------------------------------------------------
Estimate with Breakup given by hospital………….……………………………………..
Payment of Advance 80% of Rs…………………………….
.....................................................................................................................

.....................................................................................................................
.....................................................................................................................
Sanction may kindly be accorded for medical advance of Rs…………………...……
Payment may be released in favour of …………………………………...………………. ......................................................by a
crossed cheque.

Excess amount if any paid beyond the admissibility would be adjusted as per existing rules.

Dependency checked from official records
AM/P (Welfare)

JGM (Welfare & Protocol)

GGM (Admn)

GM (FE)
PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ONE OF THE APPROVED HEALTH CHECK-UP PACKAGES IN ANY
OF THE FOLLOWING HOSPITALS
(For employees & their spouses who are 45 years & above)

I.………………………………………..…......…. am willing to avail of the Health Check-up package for self and / or for my spouse

(Mr./Smt…….............………………………..............………..(Date of Birth………………….........…….) as per my choice given below:-

1. ESCORTS Heart Institute 2. Indraprastha Apollo Hospital
Okhla Road, New Delhi Sarita Vihar, Mathura Road, New Delhi

3. National Heart Institute 4. Batra Hospital
49-50, Community Centre, East Kailash, N. Delhi 1, Tuglakabad Industrial Area M.B. Road, New Delhi

5. Park Hospital 6. Fortis Hospital
1. Meera Enclave, Outer Ring Road, N. Delhi 1. B-22, Sector-62, Noida
2. Malviya Nagar, New Delhi 2. Sec-B, Pkt-1,Aruna Asafali Mrg,Vasant Kunj,
3. South City-II, Gurgaon 3. Neelam Bata Road, Faridabad,
4. Sector-10, Faridabad 4. WEA, Karol Bagh, New Delhi
5. A-Block,Shalimar Bagh, New Delhi

7. Medanta, the Medicity 8. Columbia Asia
Sector-38, Gurgaon Block-F, Palam Vihar, Gurgaon

9. Alchemist Hospital Sec. 53, 10. Dr. B.L. Kapur Memorial Hospital
Saraswati Kunj, DLF Golf Course Road, Gurn Pusa Road, New Delhi

11. Moolchand Hospital 12. St. Stephens Hospital
Lajpat Nagar, New Delhi Tis Hazari, Delhi.

13. Kailash Hospital 14. Asian Institute of Medical Science
H-33, Sector-27, Noida Sector-21A, Faridabad-121001

15. Paras Hospital 16. TIRATH RAM HOSPITAL
C-1, Sushant Lok, Sector-43, Gurgaon Rajpur Road, New Delhi

( ) Please tick against the hospital & location.

Name……………………………………. Designation ……………………………… Emp. No. ………………………….. Division
……………………….

DOB ……………………………………… Status : Regular/Deputation, Whether opted RITES Medical Facility (Yes/No)

Intercom No………………………….. Mobile / Landline No…………………………………

Signature......................................... Dated:…………………………….

Signature of the Controlling Officer with Designation
PROFORMA FOR ISSUE OF AUTHORITY LETTER TO ONE OF THE APPROVED HEALTH CHECK-UP PACKAGES IN ANY
OF THE FOLLOWING HOSPITALS
(For employees & their spouses who are 45 years & above)

I.………………………………………..…......…. am willing to avail of the Health Check-up package for self and / or for my spouse

(Mr./Smt…….............………………………..............………..(Date of Birth………………….........…….) as per my choice given below:-

ESCORTS HOSPITAL APOLLO HOSPITAL NATIONAL HEART INSTITUTE
Okhla Sarita Vihar East of Kailash
Executive Check-up Executive Check-up Executive Check-up
For males Rs.3000/- For males Rs.3000/- For males Rs.2800/-
For females Rs.3250/- For females Rs.3000/- For females Rs. 3200/-
FORTIS HOSPITAL
BATRA HOSPITAL TIRATH RAM HOSPITAL
Vasant Kunj / Noida / Faridabad
Mehrauli Badarpur Road Rajpur Road
Karol Bagh / Shalimar Bagh.
Executive Check-up Executive Check-up Executive Check-up
For males
Rs.3000/-
For males/females Rs.2100/- For males/females Rs.2175/-
For females Rs.3250/-
MEDANTA THE MEDICITY COLUMBIA ASIA ALCHEMIST HOSPITAL
Sector-38, Gurgaon. Palam Vihar, Gurgaon. Sector -53, Gurgaon
Executive Checkup Executive Checkup
Comprehensive Check up

For males/females Rs.3500/- For males/females Rs.3000/- For males &females Rs.3000/-
DR.B.L. KAPUR HOSPITAL Moolchand Hospital
Pusa Road, New Delhi Lajpat Nagar, New Delhi
Executive Checkup (For
Rs. 3000/- Executive Checkup (For males/females)
males/females) Rs. 3000/-
Kailash Hospital & Heart Institute St. Stephen’s Hospital,
H-33, Sector-27, Noida Tis Hazari, Delhi
Executive Checkup (for
Rs. 2450/- Executive Checkup (for Males / Females) Rs. 3200/-
Males/Females)
Asian Institute of Medical Sciences Paras Hospitals
Sector-21 A,Faridabad-121001 C-1, Sushant Lok, Sector-43, Gurgaon
Executive Checkup (for
Rs.4000/- Executive Checkup (for Males/Females) Rs. 3150/-
Males/Females)
Park Hospital
Outer Ring Road,New Delhi / Malviya Nagar,New Delhi / South City-II,Gurgaon / Sector-10,Faridabad
Executive Checkup (for Males/Females) Rs. 3000/-

( ) Please tick against the package of the hospital & location.

Name……………………………………. Designation ……………………………… Emp. No. ………………………….. Division
……………………….

DOB ……………………………………… Status : Regular/Deputation, Whether opted RITES Medical Facility (Yes/No)

Intercom No………………………….. Mobile / Landline No…………………………………

Signature......................................... Dated:…………………………….

Signature of the Controlling Officer with Designation